Long-Term Care Survey Alert

Clearly show you're on top of a wound's progress.

Every picture tells a story. And a series of pictures of a stage 3 or 4 pressure ulcer taken over time, combined with the right written words, may help you steer clear of F314 tags and/or huge civil judgments.

Caveat: That's only true, however, if you follow the right steps for taking the pictures and know how to back them up with medical record documentation.

Reap the rewards: "Taking pictures and providing written documentation of your care creates a paper trail of what you are doing to heal a wound," says forensic nurse specialist Dan Sheridan, PhD, RN, FNE-A, FAAN, an associate professor at Johns Hopkins University School of Nursing. "The picture can show that the wound is staying clean, debrided, infection free" -- and displaying early signs of healing, he says.

"The photograph may also be a tool for teaching the patient or family," adds Mary Arnold Long, MSN, RN, CRRN, CWOCN, APRN, CLNC, a wound care specialist in Mason, OH.

Of course, not everyone agrees that the benefits outweigh the risks of taking pictures of wounds. For example, some people will say -- "Can you imagine these pictures in front of a jury?" notes Peggy Dotson, RN, a wound consultant in Yardley, PA. But attorneys can educate juries about pressure ulcers, she says.

Follow These Policies and Procedures

If the facility is going to take the pictorial route, however, it needs to develop policies and procedures for taking the pictures. You want to take the pictures at the same distance from the wound, using the same camera -- and labeling the pictures in the same way, emphasizes Dotson.

Use a measuring device "in the wound photo to provide perspective" about the "wound's actual size," advises Long. Also include the date and some patient identifier -- for example, the medical record number or patient's initial in the photo, she adds. And make sure you use sufficient light and expose the wound to obtain a picture that provides adequate information about the wound.

Compliance tip: In this age of digital photography, a facility should have written procedures about how pictures may be manipulated -- for example, cropped or rotated -- but not altered, advises Long. Facilities should also determine how to store photographs as part of the medical record, she says.

Provide Adequate Backup Documentation

Long suggests that facilities use pictures as an "adjunct" to a "narrative assessment" of the wound that includes these parameters:

• Anatomical location

• Wound dimensions

• Wound-bed appearance

• Presence/absence of exudate

• Condition of the surrounding skin.

Survey tip: The F314 survey guidance also recommends conducting and documenting any wound-related pain the resident may have.

Snap 'before and after' debridement pics: Debriding a wound can make it look like it's deteriorated -- a change in status that could trigger F tags or complaints from family members if you don't explain why it looks worse.

A photograph can be "an effective means of documenting variations in a wound pre- and post-debridement, as long as you write a narrative description to accompany it, says Long.

Cover the Legal Bases

Keep in mind that nurses can testify in court or a hearing about the condition of a wound as they observed it on a certain day whereas non-clinical staff cannot. Thus, Sheridan "strongly recommends" assigning a licensed nurse to be the wound picture-taker -- preferably the same person to promote consistency in technique. That person can then testify, if needed, about how she observed and documented the wound when she took the picture, Sheridan says.

"Say the wound showed granulation," a sign of healing that hopefully the picture adequately portrays. The nurse could testify to the effect that "in this picture taken on Dec. 5, the wound shows more granulation than in the picture taken on Nov. 30." Even if the picture didn't clearly show granulation, the nurse could testify that she saw granulation on the day she took the picture, Sheridan points out.

Editor's note: For inside tips on staging and documenting wounds for MDS purposes, see the February 2007 MDS Alert. For subscribing information, call 1-800-874-9180.